Acct Name/Location

Account #

Mailing Address
(If blank, will mail to address on file)

Patient Info

ToFollow Supply CallWhenReady Uncut

Treatments Y / N
RLX/SS.....
Foundation.
UV.............

Photochromic
or Polarized
Grey......... Brown
Transition..
SunSensor
InstaShade
Polarized...
PGX.........
None..............

Material
(Select One)
CR39
CR39 RLX/SS
1.56
1.60
1.66
1.67
1.74

Polycarbonate
Spectralite
Trivex
Glass

Type ................
(Select One)
SV
FT 28
FT 35
Round 22
Executive
Blended
TriFocal 7x28
TriFocal 8x35
VIP

..................................
Exceed
--- ( EZ Fit )
Exceed Mini
--- ( EZ Fit Mini )
Varsity
Outlook
Proceed
Proceed II
Sola MAX
Succeed
Succeed Ws
Adaptar

.......................
Concise
Precise
Unique
Gradal
Brevity
Compact
Natural
Image
Fusion
Comfort
Picilo
iForm

Other-Specify

......................................
Cool Blue Mirror
Cool Silver Mirror
Cool Gold Mirror
No Mirror Coating

Tint
None
Gradient
Solid
Percent
Color.........

Schedule
Network
PDS

Fedex
UPS
Pick Up